The Committee for Public Counsel Services

The Committee for Public Counsel Services

Alternative Commitment & Registration Support Unit

APPLICATION FOR SORB CASE ASSIGNMENTS

Please submit application to:|

Committee for Public Counsel Services|

Alternative Commitment|

& Registration Support Unit

Private Counsel Division|

44 Bromfield Street|

Boston MA 02108

Fax(617) 988-8493

Attn: Assignment Coordinator|

Application for:Counties in which assignments are desired:

SORB Hearings______

Name:______

Law Firm:______

Office Address:______

Office Tel.:______

Mobile: ______

Email:______

Home Address:______

______

BBO Number:______

Date of Admission to MA Bar:______

Law School(s) & Date of Graduation:______

Are you District Court Certified? Yes NoDateof certification ______

Please indicate all panels to which you have applied & date of application

District Court Accepted Rejected PendingDate______

Name of county______

District Court Accepted Rejected PendingDate______

Name of county______

District Court Accepted Rejected PendingDate______

Name of county______

Superior Court Accepted Rejected PendingDate ______

Name of county/ies: ______

Murder List Accepted Rejected PendingDate ______

Criminal Appeals Accepted Rejected Pending Date______

Mental Health Accepted Rejected PendingDate______

CAFL Accepted Rejected PendingDate ______

CAFL Appeals Accepted Rejected PendingDate ______

YAD Accepted Rejected PendingDate ______

YAD Appeals Accepted Rejected PendingDate ______

SDP Trials Accepted Rejected PendingDate ______

SDP Appeals Accepted Rejected PendingDate ______

SORB Hearings Accepted Rejected PendingDate ______

SORB Appeals Accepted Rejected PendingDate ______

OTHER______Accepted Rejected PendingDate ______

Are you currently a member of a Bar Advocate Program? Yes No[*]

Name of Bar Advocate Program ______

Length of Time in Bar Advocate Program ______

Have you ever left any Bar Advocate Program? YesNo

If yes, please indicate program, dates of membership and reasons for departure:

______

Please list all certifications:

CertificationActively Accepting Cases on Panel (Y/N)

If no, please explain

______

What other languages do you speak fluently? ______

Have you ever been removed or suspended from any CPCS panel or list? Yes No

If yes, giveparticulars.

Have you ever been disbarred, suspended, reprimanded, censured, or otherwise formally disciplined, publicly or privately, as an attorney, or as a member of any other profession, or as a holder of any public office? Yes No If yes, please explain.

Are any charges or complaints now pending before any court or agency concerning your conductas an attorney, or as a member of any profession or as a holder of any public office? Yes No If yes please explain.

LIST SERVE:

CPCS administers a list serve for SDP and SORB trial attorneys. It is a valuable resource. Please provide anaddress at which you would like to receive list serve emails.

E-mail:______

Individual______Daily digest______

REFERENCES:

List the name, address and phone number of three (3) references ( ex. attorney, Judge, Hearing Officer, client) who are familiar with your work.

Name & Title:______

Relationship to reference:______

Address:______

Telephone:______

Name & Title:______

Relationship to reference:______

Address:______

Telephone:______

Name & Title:______

Relationship to reference:______

Address:______

Telephone:______

Please attach any other information which you think would be helpful to the Committee for Public Counsel Services in evaluating your application.

PLEASE ATTACH A RESUME

I hereby certify that the above and attached information is true and correct.

______

DateSignature

*If you are not part of a Bar Advocate Program, you are required to complete the Request for Waiver Form